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Doctoring in a Foreign Language

By Tara Parker-Pope April 23, 2009 11:02 amApril 23, 2009 11:02 am

Sean Justice/Getty ImagesDoctors may neglect to use interpreters for patients who speak little or no English.

Most hospitals offer language interpreters to help doctors communicate with patients. But research shows many doctors don’t use them, an issue explored in the latest Doctor and Patient column by Dr. Pauline Chen. Dr. Chen writes:

Dr. Alicia Fernandez and colleagues at the University of California, San Francisco, and at Yale University examined language barriers between patients and doctors at two teaching hospitals with excellent interpreter services. The investigators interviewed 20 residents, young doctors recently graduated from medical school who make up the clinical frontline at these two urban medical centers.

A complex picture emerged from the interviews. While the doctors acknowledged that they were underutilizing professional interpreters, many made the decision not to call an interpreter consciously, weighing the perceived value of patient information against their own time constraints. Moreover, despite their personal misgivings, the doctors often felt that this kind of shortcut was acceptable and well within the norms of their professional environment.

I called Dr. Alicia Fernandez, the senior author on the paper, to discuss her findings. I also found myself confessing that like the study doctors, I had more than once just “gotten by.” “People have discussed the findings,” Dr. Fernandez said, “and they’ve
recognized themselves. I recognized myself. If I’m rounding late at night, I might just decide not to use an interpreter. It has become an acceptable shortcut in care. But the truth is that the patient deserves to speak to the doctor as well.”

One solution in a pinch is to a ask someone in the hospital–just about anyone–to translate if time is an issue. Often it is a relative. Hospital administrators don’t like it, but they don’t have to wait half an hour for the overworked interpreter that was supposed to be here now.

As for people who plan on staying in the US indefinitely–learn English, and you won’t have this problem.

I appreciate your willingness to share in a public forum things you have done or said that you believe could have been done or said in a more healing way. Everyone benefits by these efforts to shine light on common problems in clinician-patient relationships and to encourage discussion.

While I appreciate the difficulty involved here any physician who is not using an interpreter brings a huge amount of risk upon themselves.

There ia a legal obligation to provide cultural and linguistically appropriate care under the Civil Rights Act of 1964. Title VI of the Civil Rights Act of 1964 requires the provision of “language access accommodations” for persons who are limited in English language proficiency when they access health care. This applies to any health care provider who receives federal funds including Medicaid and Medicare as well as hospitals themselves.

I also expect that any malpractice attorney would attack the concept of informed consent without documented interpreting. Add those together and I think that additional training in medical school as well as continuing education would be time well spent.

That being said I respect Dr. Chen’s public honesty about a difficult situation.

To Jack – I am tri-lingual and have lived in Brazil and Italy for extended periods of time (and still live in Italy in what I would consider an indefinite period of time). I am fluent in Portugues and Italian, however, the ‘medical’ language is COMPLETELY different than day-to-day or even professional language. It is quite possible and even probable that someone can be fluent in a language in an every day or professional situation and not feel comfortable relying on that 2nd or 3rd language for medical purposes- particularly while admitted to the hospital! If I were hospitalized in Italy, I would certainly want an interpreter to help me communicate with the doctor if they didn’t speak English.

I’m guessing this is hard for people who have not lived in another country (with a different language) to understand.

A work-around for the “waiting for the interpreter” problem is to usen an “interpreter phone” that has two handsets. Plug it into the wall jack in the hospital room. Dial the interpreter service and tell them what language you need help with. They put the interpreter on the line and you hand the extra handset to the patient. Ready, set, go.

I have no idea how much it costs. I appreciate the hospitals that spring for it.

BTW, I would not be surprised if there are federal laws that require interpreter services be offered, by “certified” interpreters, not family members.

-Steve Parker, M.D.

-Disclosure: I have no ties to device manufacturers or interpreter services.

“many made the decision not to call an interpreter consciously, weighing the perceived value of patient information against their own time constraints. Moreover, despite their personal misgivings, the doctors often felt that this kind of shortcut was acceptable…”

In other words, the doctors decided their own time and convenience was more important than the patients’ being able to ask questions?

This sounds like exactly the same kind of decisions they make with English-speaking patients.

Too bad there isn’t an anti-hubris drug. But if it existed, these doctors would probably choose not to take it. After all, it’s not their problem — it’s everyone else’s.

My layperson’s gut feeling is that a doctor should always call an interpreter if one is available. I do see two topics unaddressed in this discussion.

One: Who pays the interpreter? I don’t know if there’s an established procedure for this. Hospitals nowadays charge you $12 for an aspirin. Is the interpreter’s hourly fee tacked onto the bill? If so, will insurance cover it? If the patient brings his own interpreter who provides an inaccurate translation, does that create liability problems? Which brings us to –

Two: Language is a subset of culture. One can be fooled into thinking that just because one has translated the words, one understands what has been said – or not said. I recall reading in a collection of doctors’ memoirs (alas, I don’t have the exact citation) about an elderly woman patient from a traditional Asian rural background who was examined with an interpreter present. When the doctor asked her about gynecological problems – any genital rashes? itching? unexpected or excessive bleeding? cramps? – the interpreter told the woman in her native language: “Don’t answer that.” That interpreter was willing to protect the patient’s modesty at the risk of jeopardising her health and possibly her life.

Ideally, the doctor and patient should share both a language and a culture.

“One solution in a pinch is to a ask someone in the hospital–just about anyone–to translate if time is an issue. Often it is a relative. ”

This has been shown in multiple studies to be very inappropriate. Family members cannot be relied upon to translate accurately. Also, many health providers go so far as to use children and teenagers as translators. Although the patient may be comfortable with this, the children rarely are. Using random hospital employees is similarly inappropriate (although a good case can be made for using a nurse or nurse’s aide if necessary). They are not subject to the same training in patient privacy, nor are they professionally required to maintain confidentiality. Especially when the patient is from a small ethnic community, the employee and the patient may well know one another.

Our time is important, but sensitive, appropriate patient care is more important. Would you cut corners in other aspects of patient care because of time constraints? If you do not consider that to be acceptable, nor should you consider not using professional translators acceptable.

One big problem, however, is cost. Many insurances do not reimburse for translation services. Many physicians, especially in small practices that are struggling to survive financially, are literally losing money when they have to use translators. Translation should be covered by Medicare, Medicaid, and private insurance.

This falls under health literacy–many native English speakers don’t understand what the doctor is saying when all the Latin and shop talk is laced in. Most hospitals have interpreters–I can see this time element being a factor on a case-by-case basis. I am sure this is no one solution. Some cultures don’t want doctors of the opposite sex, others won’t discuss certain subjects at all. Some cultures are proactive, some do whatever the doctor says. I have written on this extensively–there are studies galore about how informed consent in a second language other than English can be less than informed.

Is this related to the general need for medical information to be ‘interpreted’ for the public?

Working in health care myself and observing it from a more patient perspective, I wonder if, generally speaking, doctors assume patients understand far more than they truly do understand. In this article, the problem is compounded when there is a language barrier in addition to the medical language barrier.

For many patients there seems a reluctance to question doctors when information is not totally clear, is there a similar tendency to gloss over misunderstandings that occur because a patient wants to be cooperative and not admit difficulty with English?

It would seem worthwhile to make translators more available in healthcare, and for there to be greater stress on ‘translation’ of medical terms into English – as well as other languages

I am an Emergency Physician with 35 years experience. Time is money and a doctor’ time is over $100/hour and translators are $20-50/hour. Waiting and paying for translators costs a lot of money and time which might be spent more productively. Providing optimal medical care to everyone could cost the entire GNP. We could provide a private duty nurse for everyone that could be known, do every test in the book not to miss anything, do detailed histories and physicals (neurologists spend 1 hour with most new patients just doing a neurology exam). Every good doctor takes some shortcuts but bad doctors take too many. In the end a doctor’s comfort level and understanding of the patient’s illness should determine the depth of investigation.

I understand Jack’s frustration, but it’s important to understand the following:

When are first generation immigrants who work long hours supposed to attend English classes?

How are they to learn English when they are socially isolated from English speakers (the native language is used both at work and at home)?

Why learn English when life, which is hard enough, can be lived more or less completely in the native language, within a certain language community? Learning English is often perceived by older first-generation immigrants as a lot of work for minimal gain.

I’m sure it’s frustrating, but there is a human reality behind this question of language that isn’t quite so simple.

I think the “time constraints” referenced above might also encompass medical time constraints, i.e. the need to act in a timely fashion. I have doctor friends who tell me that in an emergency situation it is often a choice between acting without a translator or risking the patient’s life/health by waiting for one.

I agree also with the comments about the difference between fluency in a language and medical fluency. I am fluent in Italian, but would be unable, particularly in a moment of duress, to participate in a conversation filled with medical jargon.

With all due respect, your “solution” to ask relatives or anyone else to interpret in a pinch is deeply flawed at best, and downright dangerous at worse. What if the relative is not completely fluent in both languages, and makes a critical but unintentional mistake, leading to a serious misunderstanding between patient and provider? What if the discussion is around a sensitive issue, such as sexual health or mental health, that the patient has a need to keep private from family members? What happens to family dynamics when a child assumes the “adult” role of translating for his or her parent? What happens when a relative intentionally mistranslates something because of their own vested biases or interests (ie, what they want to happen, or what they want or do not want their parent/child/brother to know)? These situations are not uncommon, are all-too-real, have been documented in research, and any experienced clinician who works with diverse populations will tell you stories such as these.

All patients deserve compassionate and culturally appropriate care. It is a matter of basic human values, and frequently, a matter of life-and-death.

When medical schools review applications, they should give more incentives to applicants who speak another language fluently in addition to scoring high on the verbal section of the Medical College Admissions Test (MCAT). Applicants who speak English as a second language often score low on the verbal section of MCAT and must spend more time raising the verbal score than other applicants who speak English as their first language do. As the verbal section on MCAT is not already an easy section to study for those who speak English as their first language, it remains as an even bigger challenge for people who speak English as their second and third language as many of them are barred from getting into medical schools because of the low verbal score. Many medical schools put more emphasis on the verbal score than other science sections because admissions committees strongly believe that a high verbal score on the MCAT is regarded as a fine measure to predict an applicant’s academic success as a medical student. While medical students should maintain a high reading level in English, why can’t MCAT also emphasize ways to measure practical social aspect of candidates such as the important ability to speak a foreign language?

One might ask oneself whatever happened to the section of the Hipocratic Oath that all physicians take which says: “At first, do no harm”…It would appear that lack of adequate communication between physician and patient could and would do the gravest harm!

One might also ask oneself where all of this ethnocentricity comes from, not to mention the arrogance that says a patient has no right to either communicate in or to receive information concerning their health concerns in a language they can understand.

It is an unfortunate impression and practice that our superlative medical technology will have all the answers even without patients’ participation, irrespective if the patients are conversant in English or not.

This total dependency on “lab work” has short circuited the patient care which commences when a physician walks into an examination room.

Is it not time for physicians and residents to acquire a proficiency in communicating with patients besides draping stethoscopes as an appendage and emblem across the neck while poring over lab results to diagnose?

I’ve lived in France, and speak both French and Spanish. I can tell you there is nothing as petrifying as visiting a doctor in another country, even if you speak the language fluently. There is just too much room for error, linguistically and culturally.

I agree, if you plan to make a country your home, you should learn the language. However, there is no substitute for your mother tongue.

Residents don’t have enough time to wait around for people who might or might not show up. They also can’t schedule them in advance because they are constantly being called to emergencies. Residents have no choice in these matters, they’ve got to move and they’ve got to move fast. If not, there’s hell to pay, and maybe say goodbye to that half hour of sleep tonight.

If you can’t talk to the patient RIGHT NOW, then you’re not gonna talk to them until tomorrow. That’s just the way it goes.

If you want this to change, then better cough up for a few (tens of thousands of) more residents. Can’t afford it? Oh well, you get what you pay for, USA.

As a psychiatrist, this problem becomes even more acute due to the subtlety of the language which is lost in translation, especially in psychotherapy. So much of the nuance of communication in therapy is lost and/or subject to societal norms which are influenced by culture, that I get the sense that I’m not really understanding my patient, and that they’re not understanding me, even if we have a good interpreter available. I’m so-called fluent in Spanish, for example, but even still the fine distinctions and shades of meaning that I use comfortably in my native language (English) are readily missed, both by myself and with interpreters (especially if they don’t have specific training in psychology or psychiatry themselves) It’s a real problem, and I’m open to suggestions on what to do about it.

One other issue is cost. I am a solo-practice primary care physician in a small-to-medium size town. The law states that I have to provide a translator if a patient does not speak English (let alone the malpractice concerns). I have a patient who only speaks Russian, despite having lived in our country for over ten years. I therefore have to provide a translator. The translator charges $45/hour from the moment she leaves her house, thoughout the office visit, through to when she gets home. This typically takes her about 2.5 hours (it’s a 45 minute drive from her house to my office). I personally have to pay her over $100 every time this patient comes in. However, I only get paid $70 for the office visit. Therefore I lose money every time this patient comes in ( about every other month).

Is this fair to me? No. Why can’t we ask the patient or the insurance company to provide the translator? This is one more reason primary care doctors are leaving the field in droves to open “boutique” practices.

Americans love to complain about their doctors. Pretty soon there won’t be any more primary doctors to complain about!

Thank you so much for highlighting a very important issue that is often overlooked!

I’ve always believed that what makes medicine different from engineers diagnosing machines and repairing problems is the communication and the doctor-patient relationship. The doctor-patient relationship is sacred and at the heart of all medicine. How that doctor-patient relationship is fostered is through the two-way street of communication.

Patients describe their condition and tell their story. Doctors then listen and provide their advice and expert opinions. Patients express worry, concern, or elation over the advice. Doctors then react appropriately to assuage the worry and concern or join the celebration of good news. This all requires communication from doctor to patient and more importantly from patient to doctor.

I think this particular paragraph of the piece is the most telling:

“To a certain extent,” Dr. Fernandez said, “physician-patient communication is driven by the physician’s need for patient input rather than by the patient’s need to communicate. Communication is viewed as something that is supposed to change decisions that the doctor can foresee. So the use of interpreters may have more to do with how we think about communication with our patients and less to do with our views on interpreters, limited English proficiency patients or even time pressures.”

Doctors can sometimes be authoritative and intimidating figures, if you remove the ability to verbally communicate, what will motivate the patient to talk to the doctor except for extreme pain and discomfort? Interpreters are the bridge to that gap and it pains me to see that they are underutilized due to what doctor’s perceive are time constraints and not a top priority. When seeing a patient, that patient should be the top priority. It is only prudent to make that time investment and bring in an interpreter to ensure that all that should be communicated happens.

Yes, it’s a huge hassle for the medical providers…no doubt about it, but limited English speaking patients need that extra time and need an interpreter so that they can be provided the minimum standard of care, so they could AT LEAST understand what their diagnosis is and express their own symptoms accurately and completely.

If your in the United States….learn English. This is ridiculous, if they can become a doctor surely they can learn English. I do not think any doctor that does not talk fluent English should be allowed to be a doctor.

To Julie MD, it seems you can write english very well, why can’t you talk english? You are mad about how much you make but I have just one question. How much would you make in your county. You should be grateful we allow you to even work here. Foreign Doctors take Jobs from Americans, Cause we would rather allow foreigner doctors work than educate more American born doctors

And the thing is…doctors make too much in our society, we should have health care funded through our government and taxes like all other industrialized countries do. Health should not be about money…we should all be ashamed that we money determines the outcome of your health care….sad.